Provider Relations Representative - Prime Care Coordination : Job Details

Summary

The Provider Relations Representative serves as the primary contact between providers and the organization. The position is responsible for servicing assigned providers within a defined geographic market or by service type to educate & provide assistance whenever necessary including but not limited to Claim/Billing assistance, policy/procedural education, etc. Key responsibilities include educating and servicing physicians, hospitals and ancillary providers within established guidelines. Provider Relations works closely with all other internal departments including business development, clinical operations and network management. As a key representative of the corporation, this position is expected to maintain strong communication and build positive working relationships with physicians, hospitals, ancillary providers and internal departments.

Essential Responsibilities/Accountabilities

+ Recruit and retain all provider types to ensure network adequacy.

+ Facilitates provider education and training through documented face-to-face visits, educational forums, and orientations in order to increase provider knowledge and satisfaction with the terms of their contract as well as Health Plan's benefits products, policies, programs, systems, new programs and products.

+ Provides orientation and training for all newly enrolled providers and their staff as well as annual training to the overall provider community.

+ Educates providers on care management programs, policies, and quality initiatives.

+ Coordinates with clinical operations to analyze and present data to providers in order to improve participation and/or compliance within established programs and enhance the health of members.

+ Builds physician, provider and facility satisfaction by conducting service visits both in response to provider requests and proactively on behalf of the organization. Plans, initiates, develops, coordinates, schedules and documents the visits in conformance with department standards and geographic assignment.

+ Maintains awareness of competitive activity through relationships developed with providers and their office staff. On an ongoing basis, as part of monthly reporting, documents and shares information regarding market position including all competitive intelligence that would enable the organization to position ourselves favorably, as well as successfully respond to provider needs.

+ Provides expertise and assistance with guidelines relative to provider billing and payment, encouraging participation with programs and procedures designed to create operational efficiencies.

+ Ensures that changes in billing procedures are communicated on a timely basis to all providers.

+ Provides accurate feedback to internal departments to improve accuracy of system interfaces.

+ Serves as an internal expert and develops working relationships with internal departments in order to facilitate workflows and coordinate appropriate resources for problem resolution for providers.

+ Identifies and communicates trends that impact provider satisfaction.

+ Supports the development of effective provider education, tools and communications. Creates and maintains information such as provider manuals, newsletters, mailings, provider directories and other education and publication materials distributed by the organization to providers.

+ Ensures that processes are being appropriately documented to support maintenance of the business.

+ Assists with training and mentoring of peer Provider Relations Representatives as needed to ensure departmental success.

Knowledge, Skills, Abilities & Education:

+ Bachelor's Degree in a health care administration, business, or marketing related field, or related-equivalent experience.

+ Minimum of 1-2 year's relevant business experience working in managed care or other health care related field with significant interface with physicians, hospitals and/or provider-type groups.

+ Experience in Medicaid or Medicare Managed care insurance plans preferred.

+ Understanding of health plan type contracts, operational policies & procedures, including fee-schedule components and/or common claim processes preferred.

+ Demonstrated experience with moderately complex projects involving both written & verbal discussions to physician, hospital or Provider-type entities.

+ Demonstrated ability to communicate effectively, both orally and in writing; including the ability to prepare & deliver oral presentations/educations to small and large-group audiences.

+ Excellent problem-solving skills with effective follow-through including demonstrated organizational skills.

The listed salary range represents the organization's good faith and reasonable estimate of the range of possible compensation at the time of posting. The offered salary will be determined by: Applicant qualifications and experience, education, position specific licensing/training and departmental budgets.

CDS Life Transitions is an Equal Opportunity Employer, and as such affirms the right of every person to participate in all aspects of employment without regard to gender, race, color, religion, national origin, ancestry, age, marital status, sexual orientation, pregnancy, disability, citizenship, military or veteran status, gender expression and/or identity, or any other status or characteristic protected by federal, state, or local law. CDS Life Transitions will make reasonable accommodations for known physical or mental limitations of otherwise qualified employees and applicants with disabilities unless the accommodation would impose an undue hardship on the operation of our business. If you are interested in applying for an employment opportunity and feel you need a reasonable accommodation pursuant to the ADA, please contact us at 585-###-####.